Countdown to CMS Accreditation Nears Zero Hour

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Pam WilcoxAs the January 1, 2012, deadline nears for mandatory accreditation of advanced diagnostic imaging facilities, concerned ACR officials have issued the equivalent of football’s two-minute warning, urging sidelined providers to mobilize and apply today. Government regulators have already reaffirmed their refusal to grant extensions, setting the stage for unaccredited facilities to lose potentially sizable Medicare reimbursement. Administrators should act now, rather than place their facilities in untenable situations.

Pam Wilcox, RN, MBA, the ACR’s assistant executive director of quality and safety, says, “We strongly urge nonhospital imaging facilities to start the online application process today. The January 1, 2012, deadline might be several months away, but the rigorous accreditation process—from online application to image review to final ACR approval—could take up to six months.”

Surveying the national landscape, Wilcox estimates that thousands of advanced imaging facilities have not yet applied for accreditation. Some administrators, she speculates, underestimate the preparation needed on their part. Others might be frozen in their tracks because they find the accreditation process so daunting.

Regardless of the reason for delay, Wilcox reminds providers that they can begin the ACR accreditation process today by reviewing the ACR’s accreditation requirements online, completing the ACR’s user-friendly application, beginning the internal review of clinical protocols and clinical images with supervising physicians and other technical staff, and scheduling a medical physicist to perform phantom exams—within the ACR’s allotted two-month window.

She is concerned that some providers might continue to postpone action, only to encounter unanticipated delays beyond their control, such as a local shortage of medical physicists or imaging experts in PET or nuclear medicine. “The big message from the ACR is that providers need to file an online application by July 1 in order to be relatively assured they are accredited by January 1, 2012,” Wilcox says.

The ACR’s call for prompt action is based on hard numbers. To date, the ACR’s accreditation team has found deficiencies among first filings at rates of 32% for CT, 25% for MRI, 13% for nuclear medicine, and 10% for PET (in comparison, the deficiency rate for second filings is approximately 9% for CT). “When an accreditation package is found deficient, the provider has to collect needed images again, resubmit them to us, and go through a thorough review again,” Wilcox says.

“I can envision some providers waiting until November or December to submit their images, but again, those images will need careful review by outside experts,” Wilcox says. “The ACR cannot and will not rush that critical process.” Last-minute submissions are going to meet last-minute disappointment.

Paul A. Larson, MD, FACR, chair of the ACR Commission on Quality and Safety, notes that hospitals are currently exempt from the Medicare Improvements for Patients and Providers Act (MIPPA) accreditation mandate, but as the national spotlight on radiation dose intensifies, Congress has signaled renewed interest in expanding MIPPA’s scope. “Hospitals may not greet this regulatory news with enthusiasm,” Larson says, “but accreditation ensures the highest level of image quality and patient safety, while also allowing hospitals to be more competitive with freestanding imaging centers that are already marketing their ACR accreditation.”

Wilcox agrees. She says, “Although accreditation is often linked with reimbursement, it does prompt radiologists to make critical self-assessments of their images. In addition, we get lots of feedback underscoring the importance of ACR accreditation among referring physicians and patients. We’ve seen many photos of billboards from around the nation in which facilities advertise they are accredited by the ACR.” For hospitals, then, obtaining ACR accreditation early—well ahead of the curve—makes sense.

The ACR is the gold standard in accreditation, Wilcox says, citing its streamlined and simplified online application process and concierge technical assistance from initial contact to final approval. “The ACR accreditation process is designed to help providers succeed,” she says.

Looking ahead to January 1, 2012, Larson says, “I encourage everyone to get started today. It’s much easier to go through accreditation at your leisure. If providers delay until September, they are likely